Designing effective nursing interventions.

The purpose of this article is to present issues scientists must consider to design effective experimental interventions. The efforts of nurse-researchers to test diverse interventions are consistent with the central role of interventions for the nursing discipline. Despite the importance of interventions, limited literature has addressed the actual design of these interventions. Many experimental interventions lack content validity, and others are inadequate to affect outcomes. Eight issues to consider in the development of interventions are discussed, including the conceptual basis of the intervention, descriptive research linking key concepts to the proposed outcome, previous intervention literature testing similar or related interventions, the intervention target, intervention specificity/generality, single or bundled interventions, intervention delivery, and intervention dose. Strategies are recommended for designing effective experimental interventions.

Randomized clinical trial of a quality improvement intervention in nursing homes.

PURPOSE: The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed. DESIGN AND METHODS: Nursing facilities (n = 113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group. RESULTS: With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents). IMPLICATIONS: Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

Factors associated with unplanned readmissions following cardiac surgery.

Cardiac surgery patients are at risk for unplanned readmissions due to the various complications they may experience following surgery. The purpose of this report is to critically review the literature related to predictors of unplanned readmissions of cardiac surgery patients following discharge from the hospital. A literature review was conducted from 1989 to 1999 using MEDLINE and CINAHL, with the following key words: cardiac surgery, coronary artery bypass surgery, recovery, and readmission. The literature revealed that gender and race do have an effect on how well a patient will recover following cardiac surgery. It was also found that patients with longer lengths of stay due to complications were at greater risk for readmission following discharge from the hospital. There was no evidence that decreased length of stay for this patient group led to a greater number of readmissions. Implications for nurses include the need for improved coordination of patient care and implementation of effective discharge planning in high-risk patients. Additional research is needed to develop interventions to decrease readmissions of women and African Americans and other racial groups specific to their particular risk factors for readmission following cardiac surgery.

Tissue oxygenation, perfusion, and position in patients with venous leg ulcers.

OBJECTIVES: The purpose of this study was to compare the partial pressure of transcutaneous tissue oxygen (TcPO2) in persons with venous ulcers in four positions with and without inspired oxygen. METHODS: TcPO2 was evaluated two times, 4 weeks apart at a chest reference and three lower extremity sites. RESULTS: Lower extremity resting TcPO2 levels were lower in patients with venous ulcers than in healthy adults. Minimal changes in TcPO2 occurred with position changes when subjects breathed room air. When arterial oxygen saturation was increased using inspired oxygen, TcPO2, used as an indicator of perfusion, was lower during leg elevation, sitting, and standing compared to lying supine (p < 0.05). CONCLUSIONS: Control of peripheral circulation and tissue oxygenation may be impaired in persons with venous ulcers. Leg elevation, sitting, and standing decreased wound perfusion and may not be beneficial to individuals with venous insufficiency and ulceration. Research is needed to explore relationships among tissue oxygenation, blood perfusion, compression, positioning, and venous ulcer healing.

Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS.

OBJECTIVE: To describe the prevalence, incidence, management, and predictors of venous ulcers in residents of certified long-term-care facilities using the Minimum Data Set. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 32,221 residents admitted to long-term-care facilities in Missouri between January 1, 1996, and October 30, 1998. MAIN OUTCOME MEASURES: Version 2.0 of the Minimum Data Set was utilized. Assessment items included selected measures from background information, disease diagnoses, physical functioning and structural problems, health conditions, oral/nutritional status, and skin condition. MAIN RESULTS: Venous ulcer prevalence on admission was 2.5%. The incidence of venous ulcer development for long-term-care residents admitted without an ulcer at 90, 180, 270, and 365 days after admission was 1.0%, 1.3%, 1.8%, and 2.2%, respectively. The most frequent skin treatments for residents with a venous ulcer were ulcer care, dressings, and ointments. Factors associated with venous ulcer development within a year of admission were diabetes mellitus, peripheral vascular disease, and edema. CONCLUSION: Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at-large. Residents with a venous ulcer are likely to have comorbid conditions such as diabetes mellitus, peripheral vascular disease, congestive heart failure, edema, wound infection, and pain. Based on these data, risk factors such as history of leg ulcers, recent edema, diabetes mellitus, congestive heart failure, or peripheral vascular disease should prompt clinicians to carefully plan care that will manage a resident's risk for venous ulcer development.

Initial field testing of an instrument to measure: observable indicators of nursing home care quality.

The "Observable Indicators of Nursing Home Care Quality" instrument was developed as a new measure of nursing home care quality. The instrument is based on a theoretical model of quality nursing home care grounded in data from provider and consumer focus groups. The instrument was piloted in 10 Missouri nursing homes. Subsequent versions were tested in 109 Missouri and 11 Icelandic nursing homes. Content validity was established using experts. Concurrent and known groups validity was evaluated using Minimum Data Set quality indicators, survey citations, and a process of care measure. Interrater and test-retest reliabilities were calculated as well as coefficient alpha. The "Observable Indicators of Nursing Home Care Quality" instrument is a new measure that can be used by researchers, and potentially by regulators, consumers, or providers, to observe and score specific indicators of quality care following a 20- to 30-minute inspection of a nursing home.

Caring for vascular leg ulcers: essential knowledge for the home health nurse.

Vascular leg ulcers are a significant clinical problem. Home health nurses play a critical role in caring for clients with vascular leg ulcers and require an understanding of the pathogenesis and treatment of these ulcers. This article differentiates the pathogenesis of venous and arterial ulcers and describes the critical aspects of their treatment. Interventions include modifying activity, promoting blood flow, applying compression therapy, providing local wound and skin care, improving nutrition, and treating infection.

Vascular infections: medical and surgical therapies.

Vascular infections are a serious problem, often associated with high morbidity and mortality. This article reviews the etiology, pathophysiology, risk factors, and treatment of surgical wound infections, prosthetic graft infections, aortoenteric fistulas (AEFs), and infected vascular ulcers. The primary cause of surgical wound infections is contamination by skin organisms during surgery. Prosthetic graft infections typically result from a progressive wound infection. Comorbid conditions are also related to vascular infections. Nurses should identify vascular patients at increased risk for infection, monitor them closely, and intervene to optimize the healing environment.

Effect of dressings on saphenous vein harvest incision pain, distress and cosmetic result.

Little research has examined the healing and pain associated with saphenous vein (SV) harvest incisions, and no literature has addressed the associated distress and cosmetic result. The purpose of this study was to determine whether dry sterile gauze dressings, transparent film dressings or no dressings were more effective in hospitalized patients undergoing coronary artery bypass graft (CABG), in terms of minimizing leg incisional pain, minimizing the distress of a leg scar and improving the cosmetic appearance of the leg incision scar. Patients were randomized to dressing type on postoperative day (POD) 1, completed a pain and distress visual analogue scale (VAS) on PODs 1, 3 and 5, and a cosmetic result VAS upon discharge. Overall, leg incisional pain decreased over time (p < 0.05). Females reported decreasing pain between PODs 1 and 3, while males reported increasing pain between PODs 1 and 3 (p < 0.05). The film-dressing group reported decreasing pain from PODs 1 to 3, while the no-dressing and gauze-dressing groups reported increasing pain from PODs 1 to 3 (p < 0.05). Pain on POD 5 was positively correlated with an unfavorable cosmetic result (r = 0.42, p < 0.05), and distress on POD 5 was positively correlated with an unfavorable cosmetic result (r = 0.44, p < 0.05). The results of this study are encouraging and support the continued testing of dressings to minimize pain and distress, as well as enhancing cosmetic result.

Nutrition, tissue oxygenation, and healing of venous leg ulcers.

The purpose of the prospective study described in this article was to explore nutrition, tissue oxygenation, and healing in venous ulcer patients. Nutritional risk, anthropometric measures, biochemical indices, two 3-day dietary records, and transcutaneous tissue oxygen levels were obtained. Wound surface area was evaluated 2 times, 4 weeks apart. A convenience sample of 25 English-speaking persons with 1 or more venous ulcers participated (mean age 59.8 years, 60% men, 48% white). Moderate or high nutritional risk existed in 84% of the persons in the sample. Based on body mass index, more than 50% of the persons in the sample were obese. Nonetheless, 17 of 25 persons in the sample had 1 or more abnormal biochemical nutritional indices. In addition, caloric intake (17 of 20), protein intake (15 of 20), and zinc intake (17 of 20) were inadequate to meet the needs for healing. No statistically significant relationships were found between biochemical nutritional indices, tissue oxygenation, and healing. The women in the sample were more likely to heal than were the men (P < 0.05). This study begins to document the problems of overnutrition and undernutrition in the venous ulcer population. Future studies need to explore the effects of obesity and inadequate intake on the healing of venous ulcers. Additional examination of the differences between men and women also is warranted to identify predictors of venous ulcer healing.

Nutritional risk, status, and intake of individuals with venous ulcers: a pilot study.

Chronic leg ulcers occur in at least 1% of the adult population. The healing of these ulcers remains a clinical challenge. The purpose of this pilot study was to explore the nutritional risk, status, and intake of seven patients with venous ulcers. The Public Awareness Checklist categorized two subjects as being at low risk, two as moderate risk, and three subjects as high nutritional risk. Biochemical indicators of nutritional status identified abnormalities in hemoglobin and/or hematocrit, albumin, transferrin, zinc, and total lymphocyte count. Mean daily intake was inadequate to meet caloric needs in five of six subjects. By conservative estimates (RDA), two subjects had an inadequate protein intake. Data suggest that at least some individuals with venous ulcers are at nutritional risk, have abnormalities in their nutritional status, and/or have an inadequate intake to support healing. Future research is needed to explore the relationship between nutrition and rate of healing in individuals with venous ulcers.

Frequency, manifestations, and correlates of impaired healing of saphenous vein harvest incisions.

OBJECTIVE: To describe the frequency, manifestations, and correlates of impaired healing of saphenous vein (SV) harvest incisions in hospitalized patients who had undergone coronary artery bypass grafting (CABG). DESIGN: Prospective, descriptive, correlational. SETTING: West Coast university-affiliated medical center. PATIENTS: Thirty-two English-speaking adults who had undergone CABG. OUTCOME MEASURES: Impaired wound healing of SV-harvest incisions. RESULTS: The overall incidence of impaired healing was 43.8%. The most frequent manifestations of impaired wound healing at discharge were prolonged erythema (8/32), prolonged drainage (8/32), and both prolonged erythema and drainage (2/32). Correlates of impaired healing of SV-harvest incisions were body mass index (product-moment correlation = 0.39, p = 0.026) and preoperative use of diuretics (point biserial correlation = 0.42, p = 0.016). CONCLUSIONS: Impaired healing of SV-harvest incisions in this sample occurred more frequently than previously indicated in the literature. Although severe wound infections were infrequent, a high degree of impaired healing occurred (43.8% of patients who had undergone CABG). Future studies need to explore the long-term effects of impaired healing and test interventions to mitigate impaired healing in this population.

Subcutaneous tissue oximetry: implications for wound healing and monitoring critically ill patients.

Availability of oxygen and adequate blood flow to wounded tissues are important factors for the prevention of impaired wound healing. Oxygen is essential for the growth of new blood vessels, formation of collagen, and the prevention of infection. Subcutaneous tissue oximetry, an experimental technology for evaluating tissue oxygen and perfusion, is being researched for use in the evaluation of hypovolemia, hemorrhagic shock, sepsis, and would healing. This technology eventually may assist in the management of critically ill patients by promptly alerting physicians to decreased oxygen delivery and allowing for more timely intervention.

Vascular nursing research review: 1980--1990.

The specialty of vascular nursing has developed and flourished over the last decade. Recently, the vascular nursing literature has grown tremendously. Nurse researchers have begun to explore the unique needs of individuals with vascular disease. Areas currently under investigation include individual and family adaptation to vascular disease and clinical therapeutics for individuals with vascular disease. The research literature from 1980 to 1990 is examined to determine the amount and major themes of vascular nursing research. Unexplored areas of vascular nursing are identified, and recommendations for future research proposed.